Tuberculosis in the elderly doc

Tuberculosis in the elderly

Mabel Zevallos, MDa

, Jessica E. Justman, MDb,* a

Department of Medicine, Bronx-Lebanon Hospital Center, 1650 Grand Concourse,

Bronx, NY 10457, USA b

Division of Infectious Diseases, Bronx-Lebanon Hospital Center, 1650 Grand Concourse,

Bronx, NY 10457, USA

Although the last decade has been marked by a major decline in the incidence

of tuberculosis (TB) in the United States, TB remains an important diagnosis to

consider among older individuals. The clinical presentation is often insidious and

non-specific, as is the radiological presentation. The elderly account for a large

proportion of TB cases discovered at autopsy, illustrating the difficulty of clinical

diagnosis in this age group.

The last decade has also seen changes in tuberculin skin testing (TST)

strategies and in the treatment guidelines for latent TB. In the past, TST was

recommended for almost all individuals as a part of routine health screening. TST

is now targeted at persons who have risk factors for developing active TB,

including nursing home residents.

Clarification of nomenclature has accompanied the most recent guidelines on

TST. Those with reactive TSTs have latent TB infection (LTBI) and receive

treatment for LTBI rather than ‘‘chemoprophylaxis.’’ Isoniazid continues to be

the best method of preventing LTBI from becoming an active infection. In the

past, nursing home residents or immigrants with a positive TST of unknown

duration who were over age 35 were not given isoniazid unless certain comorbid

conditions were present because of the risk of hepatotoxicity. Current guidelines

no longer use age as an exclusionary condition, however.

Treatment of active disease in the elderly does not significantly differ from

treatment of younger patients. Management dilemmas may arise when the

diagnosis of active TB infection is suspected but not proven. In view of the

poor outcome of untreated TB, empiric TB treatment should be more readily

considered in the elderly.

0749-0690/03/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.

PII: S0749-0690(02)00057-5

* Corresponding author.

E-mail address: [email protected] (J.E. Justman).

Clin Geriatr Med 19 (2003) 121 – 138